Journal Article > Commentary

Patient safety interventions are not always implemented successfully. This commentary suggests that focusing on change management and the role of middle managers can help optimize the process, foster communication, and model the learning culture required to sustain improvements from safety initiatives.

Journal Article > Commentary

Although video and audio recordings of surgery may be useful in reviewing adverse events, previously used recording devices have only been able to capture a limited amount of data. This commentary describes the development of technology similar to the aviation black box that can collect a rich data set in the operating room for researchers to use to design targeted improvements.

Journal Article > Study

Anesthesia residents who received specific training in communication strategies to challenge a supervisor's decision performed better in a simulated anesthetic emergency compared to residents who received only general teamwork training. This suggests that targeted educational strategies may be effective at flattening hierarchies in emergency situations.

Duty hour limitations have been controversial due to inconclusive evidence regarding their impact on care outcomes. This review examined the effect of work hour restrictions on surgical residents. The authors found that duty hour restrictions have fallen short of their goals, discuss unintended consequences of the strategy that diminish safety, and call for amended policy solutions to address concerns.

In the United States, patient safety is a required competency within residency training. Despite the dissemination of the WHO Patient Safety Curriculum internationally, little is known about its implementation in low- and middle-income countries. This cross-sectional survey study found that while 30 of 44 countries surveyed were considering implementing a patient safety curriculum, significant barriers to successful implementation persist.

Adverse events occur frequently in the home care setting. A previous study estimated that about 10% of patients receiving home care experienced an adverse event, and research suggests that a significant proportion of these may be preventable. Early identification of patients at increased risk for harm in the home care setting may help inform hospital discharge planning and improve patient safety. Analyzing data from two prior Canadian home care patient safety studies, researchers found that both increased dependency for instrumental activities of daily living and a higher number of comorbid medical conditions placed patients at greater risk for adverse events. A past PSNet perspective discussed safety issues associated with care transitions after hospital discharge.

Checklists have been heralded as an important tool to improve health care safety. This review examined whether the science supports that recognition. Numerous studies have been published, but the literature base hasn't been developed to fully understand the complexities of surgical checklist implementation programs.

This systematic review of quality and safety practices for oral chemotherapy found that telephone calls from nurses identified adverse medication events and supported adherence. Technology-enabled approaches such as text messaging, interactive voice response, and video-observed therapy have not been effective to date.

Journal Article > Study

According to this mixed-methods analysis of 8 years of data, the most common voluntarily reported incidents involving older primary care patients in England and Wales were related to medication errors and inadequate communication between providers. Many of these errors occurred during the transition home after hospital discharge. These data provide targets for further research to develop methods for improving safety in ambulatory care.

Nontechnical skill development has gained attention as a way to enhance patient safety. This publication highlights how crisis resource management can help develop nontechnical expertise to enhance team performance. Strategies covered in the text include situational awareness, team communication, decision making, and leadership in the acute care environment.

An accurate list of patient medications is a necessary precursor for safe medication use. One strategy to improve medication reconciliation is to provide a list of dispensed outpatient medications to inpatient clinicians upon hospital admission via an electronic medication reconciliation process. This retrospective chart review study compared a research pharmacist–generated gold standard medication list to the actual medications ordered during an admission after such a process was implemented. The study team identified medication discrepancies between the pharmacist-generated and admission-ordered medication lists and noted any inappropriately prescribed or continued medications. Medication errors were present in nearly half of the patient records; about 9% of errors were clinically important. The authors raise concerns that electronically prepopulated medication reconciliation forms may actually adversely impact medication safety. A previous WebM&M commentary discussed how to enhance accuracy of medication reconciliation.

Conflict of interest between health care providers and for-profit industry represents a patient safety concern. This qualitative study examined the relationship between physicians who use implantable devices and the device manufacturer representatives. Although physicians reported being vigilant in their relationship with device representatives and recognized the potential for conflicts of interest, device representatives were often present for implantations.

Journal Article > Review

Morbidity and mortality rounds have evolved to incorporate patient safety concepts. This review examined how morbidity and mortality rounds have been designed and used. The authors recommend tactics such as engaging a range of professional groups and presenting errors as opportunities for learning to contribute to system improvement.

Journal Article > Study

Calculation errors in weight-based dosing can lead to serious adverse medication events in children. This simulation study randomized residents in a pediatric emergency department to receive either a reference book with precalculated weight-based dosing for medications or a card providing dose per body weight that required manual calculation. Each resident completed two scenarios, one with the precalculated doses and one requiring medication calculations. Although there was no statistically significant difference in overall error rates, errors for continuous infusions and 10-fold errors for bolus medications were significantly lower in the precalculated dose group. This study demonstrates that precalculated medication doses may decrease rates of certain high-priority medication prescribing errors. A past WebM&M commentary discussed an incident involving a pediatric dosing error.

Journal Article > Commentary

Although root cause analysis is an established strategy to investigate incidents, some have questioned its effectiveness in health care. Drawing from a recent study, this editorial suggests that robust health care investment in human factors engineering and safety science is needed to help root cause analysis achieve its full potential as an improvement mechanism. A recent Annual Perspective discussed ongoing problems with the root cause analysis process and described opportunities to improve its application in health care.

Opioid-related harm is a critical patient safety priority. This case control study examined the risk of opioid overdose among children whose mothers were prescribed either opioids or nonsteroidal anti-inflammatory agents in the prior year. The cases were children aged 10 or younger who were hospitalized or died from opioid overdose, and the controls were children of the same age without overdose. Compared to the children without overdose, those who were hospitalized or died were more likely to have a mother who was prescribed opioids. Antidepressant prescription was also more common among mothers of children who experienced opioid overdose. The authors recommend specific practices for safe opioid use, including prescription of smaller quantities and secure storage of medications, which prior studies demonstrate are not yet routine. This study emphasizes the urgent need to enhance the safety of outpatient opioid use.